Tuesday, November 30, 2004

1. Hamilton-Beach's version of an electric grilling machine. I just made no-added-fat salmon with garlic and pepper in under eight minutes. And mushrooms. And asparagus. Next up, portabello mushrooms. Plus, you can flatten the darned thing out and put on flat grill plates and make pancakes for your sweetie!

2. Glad Corn. For the love of Mike, stay away from this stuff. It's salty, crunchy, a cross between Corn-Nuts and popcorn, and I think they dust it with crack. The cat even ate some while my back was turned. You can find it at any good organic food store, right under the sign that says "I'd Turn Back If I Were You."

3. Land's End flannel sheets. I have a set that Beloved Sister sent after she was done with them, and they're still the softest, warmest things I own. No frays, either, on the hems.

Drain cooked pasta and dump in bowl. Follow with enough of the dressing to coat--you may not need all of it. Let it cool down a bit.

Add:

*1 cucumber, peeled, seeded, and diced
*1 diced red pepper
*2 cans quartered artichoke hearts, torn up with your hands while you giggle
*1 pint of quartered or halved cherry tomatoes--the really sweet sort you have to stop snacking on as you cook
*enough black olives to make you hum under your breath. Kalamatas are good.
*some cheese, cubed. Mozzerella is yummy, though I'm partial to a nice mild Muenster.

You want something that's mostly veggies, with pasta as a filler. Sometimes I add tiny whole broiled mushrooms or chunks of cooked chicken. Sometimes I add bits of ham or salami. Sometimes I don't add anything extra and simply sit on the floor, eating the salad out of the bowl with my big wooden mixing spoon.

Sunday, November 28, 2004

A couple of folks have mentioned that my blog isn't the Laff Riot lately that they're accustomed to. I therefore present...

Tips for Folks.

1. If grandma is frail, confused, and 90 years old, put her bedroom on the *first* floor. That way she won't fall down the stairs and break all sorts of things.

2. Turn on the fucking light before you go to the damned bathroom. You won't break an ankle in 14 places.

3. I am the new sheriff, here to clean up the town. Deal with it.

4. You *will* get up. Doctor's orders are *orders*, not suggestions.

Don't make me tell you this again, people.

Have I mentioned lately how crazy I am about my boyfriend? I got to meet his sister in law, a woman with whom I'd love to have a couple of cups of coffee, over Thanksgiving weekend. It's rare that I approach somebody with the catlike caution that means I might make a friend, but I did her.

Also, his brother rocks my world. He mentioned casually during the evening that, as far as he was concerned, I was his new sister-in-law. Brother was rewarded with seeing me gape like a goldfish for a good five seconds.

But best of all is the way the day suddenly improves when he calls.

Enough mush. Off to the fridge for a beer; Nurse Jo is done for the day.

Saturday, November 27, 2004

I've been corresponding off-and-on with a nursing student in Arizona named John. He's married with kids and works full-time in addition to going to nursing school. That makes my jaw drop: anybody who's done nursing school, especially an accelerated program, knows that it invades your sleep, your dinner table conversation, and your showers. Working while you do it is crazy. Raising a family is nearly impossible.

So I asked him how he's managed it. In return, he sent an explanation that included a mention of his recent surgery.

John weighed 500 pounds last year. He had gastric bypass surgery three months ago, in an effort to live long enough to see his kids grow up.

People, 500 pounds is no laughing matter. At that size, as John points out, breathing is hard work. You can be smothered, literally, by your own weight as you sleep--for that reason, many really obese folks have little machines that push air into their lungs as they snooze. Walking is difficult. Your knees, hips, and back start to give out. You live with chronic pain and skin infections, as the skin folds you've got trap bacteria and fungi. Going out to a movie is out of the question, as is sitting comfortably--or at all--on the average toilet seat. Furniture breaks, beds sag, cars need struts far more often than those driven by those of us who are a measly 30 pounds overweight.

Imagine for a moment being so large that you can't have laparascopic surgery--the instruments aren't long enough. Imagine being told that for the rest of your life, a half-cup of food at a time will be a lot. Imagine having to pay more attention to food--now an unattainable addiction--than you've ever had to before in your life...and not being able to eat until you're full without vomiting immediately.

Now put all that in context with working for a living, going to nursing school, raising three kids, and trying to be a decent husband.

John, man, I salute you. You've taken on one of the toughest challenges a person can face: one that'll change your life, hopefully for the better, but that'll take time. It'll necessitate your changing your long-held beliefs and your perspectives, it'll require that you develop emotional reserves you didn't think you could.

And I'm not talking about the surgery. To do what you've done is brave and impressive and I'm sitting here, admiring the hell out of you for it.

We were discussing (not on my regular floor) the Hemicorporectomy Guy yesterday. One of the nurses asked if he had a family and kids and grandkids and so on, because she "couldn't imagine living like that if I didn't have something else to live for."

Wow.

I replied that I hoped I'd never have to make the choice, but that there was still an awful lot I wanted to do and see and learn, and that maybe I could manage with half a body.

"But you'd only be half a person" she protested.

Double wow. And this from a rehabilitation nurse. Who works with amputees and paras and quads all the time.

There's a difference between being half a person and being a whole person in half a body. Obviously. As far as I can recall, I've never met a half-person. I mean, I've never met anybody so stunted or handicapped emotionally or mentally that they weren't able to appreciate, at least on some level, the same things that the rest of us do. People who are persistently vegetative or profoundly mentally handicapped respond well to touch and music and other sorts of stimulation; just because they can't talk politics doesn't make them a half a person.

Likewise, losing the bottom half of your body doesn't make you a half a person. You still have a brain, a mind, and the technology to get around physically. You can still roll around the middle of Seattle or Paris or wherever you'd like. You can still type, write the Great American Novel, or compose music. It would take determination and imagination and a hell of a lot of help, but you're not half a person without your legs.

Living only for your kids and grandkids in that sort of situation strikes me as unfair, both for them and for you. Maybe your kids and grandkids would feel terribly guilty, knowing that you didn't want to be alive, really, except for them. And what sort of barriers are you setting up to your own growth if you say, "The only reason I'm alive today is for you"?

Hell of a burden to bind on anybody else's shoulders, I say.

In other news

You'll notice a new link on this page. The link goes to Ivo Drury's medical blog, which is part of his physician career consulting site. I'd mentioned some weeks ago that I was considering taking advertising here, and this is it. I feel okay about imploring readers to click his links because I click them myself. Ivo is a concise, entertaining writer. He expresses the humanity necessary in medicine in ways that anyone can understand. He's not afraid to expose his own vulnerabilities or talk about his own mistakes.

So click the damned link, already.

Nota bene: I am being paid for hosting his ad, yes. The monies that come in from that are going to charity: half to pay for an annual exam at Planned Parenthood for some person with no money and half to pay for shots and a check-up for some puppy or kitty-cat with no dough at my vet's office. So not only are you helping out Ivo by reading his stuff, but you're helping the poor and downtrodden mammals of my town.

Thursday, November 25, 2004

There is a man, currently on a different floor of the hospital, who will be coming to us after his next surgery. His previous surgeries have been to debride decubitus ulcers (pressure or bed sores) and to create an ileostomy and urinary diversion in his abdomen.

This man will have half his body removed, a la the magician's trick of sawing the lovely assistant in half. Only for him, it'll be real. And dangerous; there's a strong chance that he won't survive the surgery. Even a high amputation of one leg is tricky; taking a person's lower half off is bound to be a stinker.

He was sent home to die by several other hospitals. He has chronic infected bedsores (he's paraplegic), has become septic, and was seen as a non-starter by surgeons. He's also in his early forties and is intact save that his legs don't work and have turned against him with gangrene. So he decided to take the chance of dying during surgery for the opportunity to live a whole life in half a body.

If I sound lighthearted, it's because the thought of this surgery scares the bejeezus out of me. Imagine waking up after surgery with your lower spine, your buttocks and genetalia, your legs...gone. On purpose. It sounds like something out of a bad horror movie, doesn't it? But it's an option that this man discovered on his own, researched, and then convinced one of our doctors to consider. She did, and now he's scheduled to be sawed in half (in a measured, careful way) so that he doesn't die of various infections.

After which he'll come to our floor for recovery, then move on to rehabilitation. Most nurses might see one or two hemipelvectomies (those are amputations that remove a leg and half the pelvis, usually for cancer) in a lifetime; the chances of seeing somebody with a hemicorporectomy are quite slim. For that reason we've all been researching and reading articles and discussing this case for the last two days. It's a way to prepare; the nursing care is sure to be challenging.

So will the emotional aspects, and not just for the patient. When you see somebody who's shy an arm or two or a leg or two, you don't automatically assume that that person is thereby less of a person. The idea of losing so much of your body, though, makes you question whether or not the person's person-ness will be adversely affected. It also makes me face my fears of traumatic amputation (or planned amputation, for that matter) and the fears I have of something so uncontrollable, so horrible happening that I would consider such a thing.

On to lighter topics

My Culinary Institute of America-trained, three-star chef boyfriend asked me today how to roast a turkey. "Bake at 325 or so until the thigh registers 180 on a meat thermometer...wait. You don't know how to roast a turkey? You've never roasted a turkey??" Turns out he doesn't like turkey and never bothered to learn how to roast one. If he gets any compliments on the turkey at La Schwankienne Restaurante today, I'm taking credit.

Which might just balance out the fact that the rolls I made for his family dinner tonight, to his instructions and with his recipe, suck. Maybe they're supposed to be that way. All I know is that if he'd've let me make my own damn rolls, we'd be chomping our way through mounds of doughy goodness tonight rather than breaking teeth on hockey pucks the way Grandma used to bake 'em.

Speaking of, I have just over an hour to shower and dress for The Big Family Dinner. Yes, Mom, I am bringing a hostess gift. Hope everybody has a happy Thanksgiving, no matter what bits of you may or may not still be attached.

Saturday, November 20, 2004

Employee reviews were yesterday. Everyone on the floor was rated a 3 on a scale of 1 to 5, three being "meets expectations". Ones are apparently reserved for nurses who, you know, actually kill patients, while fives are reserved for the Holy Ghost Incarnate types who work immense amounts of overtime, spend hundreds of hours each year on clinical ladder work, and generally overachieve.

For what it's worth, I got two fives--one for "talks to her patients as though they're human beings" and "takes time to explain the niggly shit that nobody else does".

Still, there are things that bother me about this. Why, for instance, would a manager simply mark everybody at "meets expectations"? There are a couple of folks on the floor who most decidedly do *not* meet expectations. I was always under the impression that reviews were supposed to give you something to work on as well as kudos. And why would a manager who spends most days on a different unit bother to rate our practice at all? Why not leave that to the sub-managers, the people who actually see us practice? Why not give us something useful rather than simply playing it safe?

It's an interesting sidelight to this that the manager has specific goals for all of the nurses on the floor: Everybody Has To Do Everything. We have three "special" programs on the floor: clinical ladder, preceptoring, and COU.

The close observation unit is something I've written about before, so I won't go over that again. Preceptoring is, basically, taking on a new nurse or a new-to-us nurse and training them in the procedures and patients that they're likely to run into on a neuro floor.

Preceptoring takes a person with a lot of patience and a well-organized mind. I have a well-organized mind but a shitty memory and zero patience with students. Realizing that, I told Manager yesterday that I will not precept. Period. "But you're good with the nursing students" Manager protested. Yeah, for five minutes at a stretch. Give me the same person for six or eight weeks and I'll turn into a snappish martinet. There's no need to traumatize a new nurse in order to prove that I'm not good at teaching; I've done it before and know my limitations.

The other bugaboo is Clinical Ladder. This is a hospital-wide program designed to make nurses more competent in their specialty, as well as to introduce them to the wide world of volunteer work and training other nurses. We do get paid more if we complete the clinical ladder program, so there are compensations besides being a Champeen Form-Filler-Outer.

At the end of the day, all CL proves is that somebody is willing to copy articles, post them, and cram for a cert. exam once a year. There's no standard formula that tests whether a nurse on the ladder is actually becoming more competent. Those who invest the time in CL are generally those who 1. live in the city and don't have to commute, 2. work three-quarter time or only on weekends, or 3. are generally recognized as being such strange people that it's inconceivable that they'd have a life. Petty but true, that last one.

I'm pretty damned competent, as are most of my colleagues. We see no reason why, as a group, we should be expected to conform to a standard set apparently at random by someone who isn't competent in our field (Manager is a cardiac nurse, not a neuro nurse) and who doesn't live in our unit.

I guess what bothers me about this whole culture of standardization is this: We work with patients who have weird brain things going on. Every patient is different, as is every nurse. Yes, there are some similarities among people who have subarachnoid hemorrhages, as there are among people who specialize in neurology...but you can't expect total uniformity inside either group.

If you hired me because I'm unique, then let me *be* unique. Don't pressure me to do things that I'm just plain not good at, like preceptoring, or expect me to produce the outward flourishes that signify competence instead of demonstrating competence. If you want good nurses, let us be good nurses. Let us spend time with our patients rather than pressuring us to copy yet another article from JAMA.

I probably have more esoteric crap stuffed into my brain than almost anyone else in the unit. I read compulsively and widely. My talent is Translating Medicalese Into English For The Benefit of Civilians. I'm good at what I do. I'm as intelligent as almost anybody else and more so than a number of people...but the current standard, as it's been put into place by Manager, doesn't allow me to demonstrate that.

Nor does it allow other nurses with different talents to demonstrate those talents. It's the standardization that bugs me. We're a tight group of loose cannons. We demonstrate our strengths every day. Watch us instead of asking us to fill out yet more forms. You might learn something.

Monday, November 15, 2004

There's nothing like being awakened three times during the night by someone else's child, then treated to the sound and sight of repeated temper tantrums at 0630 in the morning on your day off. This is why I do not have children. This is also why I left The Boyfriend's house this morning without coffee or a shower.

Please explain to me why people can drive like bats out of Hades when it's raining and pissing and visibility is what you'd see in, say, the middle of a tar pit, yet slow down in the same construction zones on perfectly clear nights. There are two construction zones--the sort with no shoulder, where three lanes of traffic zoom between concrete barriers--between me and work. Every clear, lovely night people slow down and we crawl through at 25 miles an hour. On nights like Saturday night, when it's raining cats and dogs, they blast through the flooded areas going 80. Riddle me that.

If you tell me that you're friends with the hospital board president, it will not make me treat you any better. Especially if you're obnoxious. Let's face it: unless Mister Bigshot is in the room with you, holding your hand, you're just another patient.

My hospital hobbyist is now in isolation. Unfortunately that means little or nothing to HH's spouse, who insists upon heating up dinner in the communal microwave and removing equipment from the room. Given that these are the same people who think that empty rooms are good for taking naps or entertaining the kids, I'm not surprised...

Goodness. In my current mood, the only thing to do is scrub the shower. That'll make me feel less grouchy, and I'll end with a sparkly clean bathtub.

Sunday, November 14, 2004

Especially a fireman who's just gotten off his 24 hours. An English fireman (that is, an Englishman who's here fighting fires) at that. Perhaps especially, never ever drink with an English fireman from Islington, a place that apparently endows its children with heart of oak and liver of stainless steel.

If you do decide to drink with a fireman, do not trade stories about work. If you do decide to trade stories about work, do it somewhere other than a quiet pub. Otherwise, people might start to look at you funny.

At least I know that my job, whatever its adventures, is not so bad. "What's the hardest thing you've done lately? Trauma?" I asked. "Oh, no" he replied. "Trauma is easy. CPR on a 400 pound corpse is hard." "How corpsey?" "Very, very corpsey."

In other news

We have four ICU overflow beds on our floor. That is, when the intensive care unit is tippy-top full, the Powers That Be send the extra neuro ICU folks to us. I worked a shift this weekend in the overflow unit, with--thank you, God--only one patient, and her with only one drip.

Having ICU overflow beds on a regular floor is a bad idea. The number and type of monitors, drips, and tubes your neuro ICU person has wired into his head or heart requires that the room be set up differently and that it be out of the way, in a place surrounded by signs warning of the Dangers of Cellphone Use. That means that the only practical place to put overflow patients on our floor is in a suite of rooms off in the boonies where nobody can hear you scream.

More importantly, we are not ICU nurses. Hand me a patient with a nicardipine drip (used to control blood pressure) and I can handle it without too much trouble...but I don't like it. I'm not in practice for it. Telemetry, while not a completely closed book, is not something I do every day. I can bumble along, true--but bumbling along is not something you want for a person who's sick enough for the ICU.

It was lucky for everyone involved that my patient was stable.

How to be an addict

If you're poor, you'll have to get your hits from the street or a series of ERs. If you're rich, you can milk a few months out of various hospitals with a series of ever-more-complex problems that require Demerol and Phenergan to treat. If you're rich and well-connected, you can find a doctor who will diagnose you with a rare disorder, one that requires diagnosis by exclusion, and you can run with the Dilaudid for years on end.

One of our pet Hospital Hobbyists came in three weeks ago and is still with us. This patient is still getting various fun narcotics to control pain that's caused by a rare disorder--one that allows a significant amount of activity in the hospital but apparently renders one inable to go home to perform the same activities. Dilaudid every two hours, nausea medications every four, and a tea-time dose of some sort of tranquilizer is helping the Hospital Hobbyist get through the day, see friends and relatives, and take a little vacation from real life.

I had another of the Hobbyists a few months ago, with the same attending physician, and got into an argument with said physician over my unwillingness to push 50 milligrams of Phenergan and 8 milligrams of Dilaudid every two hours. For those non-nurses in the audience, these are drugs at doses that would knock down a small hippopotamus for several hours. Yet the Hobbyist in question was still happy and conversant, completely sane, and relieved that the withdrawal symptoms had stopped for a bit. Not that any Hobbyist would ever admit that, of course. Nor would a Hobbyist appreciate the observation that their hospitalizations tend to come over holidays and other high-stress times in their lives.

Don't ask me why people do this. Don't ask me to speculate on how they get this way or why their physicians allow the behavior to continue. I swear that when my liver decides to cut out the middleman and hop out of my body to find a bar on its own, it won't have to go past hospital security to do it.

Saturday, November 06, 2004

"Comfort women." Nice. Just...well, I'll be honest with you. I understand that a blog's a blog; that people can be just as sweet or as nasty or as purposefully inflammatory as they want, and that a lot of folks are inflammatory for fun. We'll take that as read; I'm not naive enough to believe that everything written in the NetWorldBlogOSphere is meant to be taken seriously.

But "comfort women"? Uh...do the thousands of Korean women who were tagged with that name originally not mean anything to you?

Curb stomping and comfort women. Amazing. Makes me wonder if somebody like Joe Lieberman is, in this guy's eyes, a Comfort Heeb. You know, not too bright, but good with the deli meats and bagels.

Holy shit. This is the reason I'm not moving to Canada. Specifically, the likes of Ann Coulter and William Bennet are the reason I'm not moving to Canada. *Somebody* intelligent has to stay and enunciate the other side's views.

Friday, November 05, 2004

Geena at Code Blog has a story that every nurse can echo: the conundrum of the patient whose doctor is unwilling to let him die the way he'd like. When something like what she describes starts to go down, everyone around gets involved--the family, the nurses, the residents. Sometimes it works out. Sometimes it doesn't. Here, from my own experience, two stories that came swimming back to the top of my head after I read Geena's post. Note that these are even more heavily fictionalized than usual.

Case #1: Bill W.

Bill W. was a high-powered executive with a large national company based in our town. He was well-liked, considered by friends and coworkers to be a highly ethical, stand-up kind of man. He had a large supportive family. He was diagnosed with lung cancer at 45 and, with extensive treatment, went into remission.

His remission lasted twelve years, at which point he ended up with brain, liver, and spinal metastases. The prognosis was quite poor; you rarely end up beating back a disease as aggressive as lung cancer more than once. He ended up in my care on the medical floor. The first day he was communicative but disoriented. The second day he was responding to touch but not making any sense. The third day he stopped responding at all.

He and his family agreed that he should be no-coded (ie, a "DNR," or "do not resuscitate") and that treatment should be palliative. His doctor, on the other hand, was unwilling to let his patient die. On the third day I had Bill in my care, his doctor wrote orders for IV fluids at 125 ccs per hour (about half a cup; much more than is necessary for palliative care), every-six-hour fingersticks for blood glucose, insulin injections, and three different IV antibiotics.

The man was comatose. His kidneys had failed; he was producing about three tablespoons of urine in an hour. What his kidneys couldn't get rid of had settled in his legs, his scrotum, and his lungs. His hands and arms were swollen and bruised from repeated IV sticks and lab draws. His breathing was harsh and slow, with long periods of apnea.

The resident and I got into a very polite shouting match about his treatment. I told her that it went against my grain to go against his and his family's wishes for his death; she told me that her boss (his attending physician) felt he had to "try everything" for the man and the family he'd known since childhood.

Eventually, the family's and my viewpoint carried the day and Bill was put on an IV morphine drip. Palliative care was all we gave; we stopped the insulin injections and the antibiotics. He died the next afternoon with his family in the room with him; I bathed his body and walked it to the morgue.

Who was right? Who knows? Who can say that a person at the edge of death, unable to talk or make his wishes known, might not experience a change of heart and want others to do whatever's necessary to bring him back? Is it cruel to run IV fluids and antibiotics and stick somebody with needles when they most likely can't feel it, or at least can't translate the pain into anything meaningful? And would the person in the bed want to go through all that, if it meant that his wife and kids could sleep better at night?

Case #2: Kelly G.

Kelly was involved in a one-car accident that left her in a persistent vegetative state. The trauma of her accident had led to one of her arms being amputated below the elbow and one leg being amputated above the knee. She had a tube going into her stomach for feedings, a trach to breathe through, and a tube coming out of her belly just above her pubic bone to drain urine. She came to our floor without purposeful response to anything including pain, with only basic brainstem reflexes, and with very sluggish pupillary reflexes.

She also, because of the sort of trauma she'd had, had seizures. In order to relax her rigid muscles and prevent the seizures, she was on a number of medications, all of them sedating.

By the time I saw her the first time, she'd been like this for four years. She'd endured seven bouts of pneumonia, uncountable urinary tract infections, bedsores, and her limbs were contracted from lack of use. Her parents had bankrupted themselves to care for her. They were convinced that she would someday wake up and begin to respond to them in a meaningful way.

Shortly after her last hospitalization with us, her parents began to wean her off of all sedating medications, including the ones that were preventing her seizures. Their theory was that the medications were delaying or derailing any chance she had of getting better. Within six months she'd had six tonic-clonic ("grand mal") seizures. One had lasted three and a half minutes, a long time for a seizure. Her spasticity had gotten worse, and she'd begun to vomit tube feeding and inhale it, thus setting herself up for more bouts of pneumonia.

But her parents persisted, thinking that at some point she would, in the words of one of my more blunt colleagues, "Sit up and ask for a Pepsi."

Again, who's right? I can't imagine what her parents went through, having a bright and talented 16-year-old who came so close to dying and returned to them far from intact. Was it cruelty to keep her alive on life support in the first place? What about each successive case of pneumonia? Should one of them have gone untreated? And is it ethical to subject a person, no matter how unable to think or feel or respond, to repeated seizures in an attempt to bring them out of the shell that brain injury creates?

And the question comes up again: would the patient have wanted to go through this in order to spare her family the late-night what-ifs?

At the end of the day, I guess it's just not up to us, as caregivers, to have the definitive answers to those questions. The best you can do is to have some sense of when things are crossing the line for you, personally, and when you have to get somebody else to provide care. Sometimes it's hard like this; most of the time things are easier. Thank God.